Ld. Advocate(s)
For complainant .. Sudipta Biswas
For OP1 & OP 2 .. None
Date of Filing : 26.07.2018
Date of Disposal : 24.12.2018
: JUDGMENT & ORDER dtd. 24.12.2018 :
The case of the complainant, in brief, is that the complainant being a senior citizen purchased one Health Insurance Policy from the OP 1 through OP 2 vide policy No. 120100/12001/2017/A007631/377, policy type-Individual plan and the name of the plan-is Easy Health Group Insurance. On 12.05.2018 at about 7.30 p.m. one bicycle dashed the complainant at Tehatta Bazar, as a result, her right leg was broken. Thereafter, she was taken to Tehatta S.D Hospital. But due to absence of doctor the relative of the complainant admitted her at Fortis Hospital, Kolkata on 13.05.2018 and she was treated there till 23.05.2018. At the time of said accident the complainant had valid Health Insurance cashless card being policy No. 120100/12001/2017/A007631/377 and ID No. 782140. During her treatment the complainant claimed medical expenses before the OP No. 1 but OP 1 did not pay the said bill amount. On 26.06.2018, the OP 1 illegally and whimsically rejected the said claim of the complainant by a letter. Thereafter, the complainant informed the whole matter before the OP 2 on 16.05.2018, 29.05.2018, 25.05.2018 by written complaints and also informed the said matter at local P.S. vide GDE No. 569 dated 16.05.2018 but they did not pay any heed to it. Finding no other alternative the complainant has filed this case praying Rs.2,63,627/- along with Rs.20,400/- as expenses of treatment and ambulance charge, compensation of Rs.10,00,000/- for mental pain and agony and litigation cost of Rs.15,000/-.
The complainant has filed some documents which are marked as Annexure – 1 to Annexure – 22.
She has also filed an examination-in-chief as PW 1 which is same as stated in the petition of complaint.
On the other hand, notice was duly served upon the OP No. 1 and OP No. 2 but they did not contest the case. So the case was heard ex-parte against the OPs No.1 & 2.
Points for discussion
- Whether the complainant is a consumer under the CP Act, 1986?
- Whether repudiation of mediclaim policy of the insurer / OPs was justified or not?
- Whether there was any deficiency in service on the part of the OPs in respect of mediclaim?
- Whether there was any unfair trade practice on the part of the OPs in respect of her mediclaim policy?
- Whether the complainant is entitled to get any relief /reliefs as prayed for?
Decision with reasons
Point No. 1.
The OP No.1/ Insurance Company approached the Complainant through OP No.2, the Bank Manager, Canara Bank with a proposal for Mediclaim Policy at a monthly premium of Rs.5,881/- for the complainant and her husband. Being convinced by the approach of the OPs, the said proposal was accepted by the complainant and accordingly, the premiums were duly paid month by month by the complainant in favour of the OPs. Therefore, it can be safely said that there is a relationship of consumer and service provider between the complainant and the OPs No. 1 & 2. So, the complainant is a consumer within the purview of Consumer Protection Act, 1986.
Thus, point No.1 goes in favour of the Complainant.
Point No. 2:
With regard to point No. 2 whether the repudiation by the Insurance Company was justified or not? In this context, there are ample decisions of the Apex court holding the view that the senior citizen avails mediclaim by paying fat premium every month only to get hassle free medical treatment in their old age. In this case despite the fact that Insurance Company received the policy premium but when the benefits were required to be extended to the complainant / family members it closed the claim with a vague / stereo type reason that pre exists disease at the time of taking policy. But there is no other document on record except the discharge summary of the complainant issued by the Fortis Hospital where she was admitted and remained under treatment. So merely, on the basis of past history mentioned in the discharge certificate, it cannot be said that the complainant was suffering from pre exists disease and she intentionally concealed the said material fact. The same view was expressed by the National Commission in the following Judgment; United India Insurance Co. Ltd. & Anr. Vs. S. K. Gandhi, 2015(2) CLT.71(NC), Satish Chander Madan vs. M/S Bajaj Allianz General Insurance Co. Ltd. 2016 (1) CPJ 613(NC) in which it has been held that the burden was on the OPs to prove that the complainant had concealed material fact of her pre exists disease at the time of taking policy.
The Ld. Advocate appearing for the complainant made a submission that the complainant repeatedly informed both the Bank Manager and the Insurance Company regarding her metal valve repair in the year 2000 at the time of taking Policy but the OPs never objected anything at that relevant point of time and assured her of insurance claim. Moreover, the accident took place on 13.05.18, i.e., after 18 years of the metal valve repair and the complainant’s right leg was broken when the bicycle dashed her. So the metal valve repair in the year 2000 has nothing to do with the present accident claim.
In another landmark judgment of Chandigarh High Court on an insurance claim by one Jai Prakash Tayal against United India Insurance Corpn. Ltd., the High Court took the opportunity to highlight that “Citizen requires a lot of effort and time to get their claims passed. It is usual to see claimants running from pillar to post to get medical reimbursement from Insurance Company.
Justice Pratibha M. Singh held that a clause in the insurance policy excluding a person with “genetic disorder” from availing its benefit was discriminatory and contrary to public policy, adding that exclusion on the ground of individual ‘s genetic heritage can be valid only if it backed by rigorous and exhaustive tests. It has further held that “Right to avail health insurance is an integral part of the right to health as recognized in Article 21 of the Constitution.”
Thus, in the light of the above landmark judgments it can safely be said that the repudiation by the Insurance Company was not justified.
Points No. 3 & 4:
With regard to Points No. 3 & 4 there are ample proofs to show that there were deficiency in service on the part of the OPs. Firstly, the rejection of cashless mediclaim reimbursement tantamounts to gross deficiency in service on the part of the OPs.
Secondly, instead of reimbursement of the amount the insurance company went ahead and cancelled /terminated the Medical Insurance of the couple by a letter dtd.15.05.2019 i.e. after the accident occurred on 13.05.18. The termination is an afterthought process and hence illegal. Thus, it is clear case of unfair trade practice causing immense trouble and harassment to the complainant.
Therefore, on the basis of discussion discussed above, we have come to the conclusion that deficiency in service & unfair trade practice have been proved by the complainant beyond all reasonable shadow of doubts against the OPs.
Point No. 5.
On the basis of discussion as a whole, we are of the view that the complainant is entitled to get reliefs as prayed for.
Hence, it is
O R D E R E D,
That the instant case be and the same is allowed ex-parte against the OPs No. 1 & 2.
The OPs No. 1 & 2 are hereby directed to pay Rs. 2,63,627/- for expenses of treatment and Rs. 20,400/- for ambulance charge to the complainant either jointly or severally within 30 days from the date of this order, failing which an interest @12% p.a. shall be imposed on the aforesaid amounts till full realization.
Both the OPs are further directed to pay Rs. 10,00,000/- as compensation for causing mental pain and agony and litigation cost of Rs. 15,000/- to the complainant either jointly or severally within 30 days from the date of this order.
Let a plain copy of this judgment & order be furnished to the parties forthwith free of cost.
